Pathological airway issues frequently masquerade as more severe forms of the physiological respiratory and airway symptoms that many pregnant patients describe. Disorders of the airway are often exacerbated by pregnancy; persistent or worsening dyspnea must be investigated. Gold standard investigations that involve radiation exposure should be used appropriately for diagnosis and surveillance. Goitre is endemic in many countries and often worsens in pregnancy, which places the patient at risk for tracheomalacia. Idiopathic subglottic stenosis is a disease of women in the child-bearing years, and while easily treated, needs to be first diagnosed. Anterior mediastinal masses are unfortunately frequently missed as the presenting symptoms are ascribed to pregnancy changes. Airway changes in pregnancy lead to sleep-disordered breathing and are worsened by preeclampsia. The airway worsens in labor and can transform an awkward airway into a difficult one. Current airway management guidelines should be followed, with specificity for the pregnant patient, ensuring equivalent airway equipment and airway expertise are available for women with known airway issues. Finally, the pregnant patient with a known structural airway issues must be managed in a centre with access to airway experts, surgeons, and cardiopulmonary bypass or ECMO to ensure outcomes are good for both mother and baby.

The unique hormonal environment of pregnancy causes several changes to skin, hair, and nails. These changes may alter the appearance or behavior of chronic skin conditions, necessitating management changes. Additionally, the anesthesiologist may encounter several pregnancy-specific dermatologic conditions, some of which have broad implications for anesthetic management. Dermatologic drug safety in pregnancy is also a significant concern, as many of the medications commonly used outside of pregnancy are considered teratogenic. A thorough understanding of common dermatologic disease states and their implications on anesthetic management is crucial for the practitioner of obstetric anesthesia.

Ultrasonography is a safe, relatively inexpensive, and portable imaging modality. With the increasing availability of mobile, portable, and pocket-sized ultrasound machines, point-of-care transthoracic echocardiography has become a bedside tool to serve in medical emergencies and in peri-operative settings to assess the hemodynamically unstable obstetric patient in a timely fashion. In managing obstetric critical illness, some characteristics of pregnant women facilitate a focused cardiac examination, including anterior and left lateral displacement of the heart, spontaneous ventilation, and familiarity with ultrasound use. It supplements the physical examination, basic investigations, and aids in the diagnosis of significant cardiac pathology. While many acronyms exist, such as bedside echocardiography, point-of-care echocardiography, hand-held echocardiography, or goal-directed echocardiography, national and international scientific bodies have agreed on the terminology “focused cardiac ultrasound” or FoCUS. This chapter provides an overview of the definition, techniques, and diagnostic aims of a FoCUS examination and its clinical applications in obstetric cardiac disease. The chapter concludes by summarizing certification standards and training requirements.

Perinatal substance use disorder is a chronic medical condition affecting between 2-5% of the population, characterized by uncontrolled use of a particular substance despite harmful consequences. Substance use disorder is increasing in frequency in the United States, particularly among women of reproductive age. It is associated with increased risk for fetal-neonatal conditions such as growth restriction, fetal alcohol syndrome, and neonatal abstinence syndrome and places patients at risk for morbidity and mortality. In this chapter, several specific substances are considered in the context of pregnancy.

Short stature (height < 148 cm) is caused by a heterogeneous mix of conditions with genetic, constitutional, or metabolic origins. It can be classified into conditions causing proportionate or disproportionate short stature depending on the trunk-limb ratio. Disproportionate short stature is largely due to the skeletal dysplasia disorders, of which achondroplasia is the most common condition. Pregnancy and delivery are high risk periods in these patients given the increased risk of cardiorespiratory compromise from the physiological changes in pregnancy in addition to the high risk of cesarean deliveries from cephalopelvic disproportion and decompensated maternal and fetal conditions. Anesthesia management is challenging as anatomic abnormalities result in increased difficulty and increased risk of complications with both neuraxial and general anesthesia. There are also challenges around use of equipment, intraoperative monitoring, dosing of neuraxial anesthesia agents and postoperative management. Despite these difficulties there is a significant number of reports in the literature on the successful management of parturients with short stature. These reports can help guide anesthesiologists in ensuring the safe care of this unique patient population.

Myopathies are a group of clinical diseases that impair the function of skeletal muscle. The muscle fibers are affected directly, as the innervation and neuromuscular junctions remain intact. Although a primary symptom is often weakness, variable patterns of stiffness, contractures, or cramping may also be present. These symptoms are often exacerbated by the physiologic stress of pregnancy and labor, which may unmask a previously undiagnosed myopathy. The hereditary myopathies include muscular dystrophies, congenital myopathies, metabolic myopathies, and disorders of muscle membrane excitability. Inflammatory myopathies are a subset of acquired myopathy. Each classification has specific obstetric and anesthetic considerations, which will be described in detail.

Peripartum psychiatric disorders are common, and it is likely that an obstetric anaesthesiologist will be involved with the care of a patient with one of these disorders. The most common psychiatric disorders encountered in the peripartum period include depression, anxiety, bipolar disorder, post-traumatic stress disorder, and schizophrenia. These conditions are commonly underdiagnosed and undertreated but may have grave maternal and neonatal consequences. Additionally, postpartum psychiatric disorders, specifically anxiety and depression, are common complications of childbirth. The rising prevalence of these disorders in the peripartum period necessitates an understanding of the epidemiology, management, and treatment options. Evidence on how psychiatric disorders and their treatment can affect the mother, baby, and the delivery of anesthesia care is presented. This chapter reviews important anesthesia considerations for pregnant patients with psychiatric disorders and interactions that may occur between anesthesia and the medical management of these disorders. Additionally, interventions and prevention techniques to improve patient care and manage postpartum psychiatric sequelae are explored.

Genetic disorders commonly present or show severe manifestations early in life and in reproductive-age women. The impacts of such disorders in pregnancy are complex, often involving both mother and fetus. This chapter provides an overview of key concepts in genetics, focusing on the patterns of inheritance of monogenic disorders. The features and management of several common disorders are discussed, including alpha-1 antitrypsin deficiency, autosomal dominant polycystic kidney disease, Charcot Marie Tooth disease, Ehlers Danlos syndrome, Loeys-Dietz syndrome, glucose-6-phosphate dehydrogenase deficiency, Down syndrome, Turner syndrome, and mitochondrial disorders with a focus on management considerations, relevant for the practice of the obstetric anesthesiologist.

This chapter discusses a variety of miscellaneous conditions found during pregnancy, each with different degrees of rarity. It focuses on the pathophysiologic changes that occur with each disease in order to highlight the impact on both anesthetic and obstetric management. However, as some of the conditions described have a wide and varied organ involvement, firm management conclusions cannot be made. Each case should be assessed individually and may necessitate a multidisciplinary approach involving obstetricians, anesthesiologists, and neonatologists.

Many inherited conditions result from disorders of intermediary metabolism. Many more are discovered annually using advanced gene sequencing and other tools. These diseases cause symptoms because of the accumulation of precursors, absence of the final product, excessive toxic intermediaries, or a combination of all three mechanisms. Many are fatal in childhood, but some are compatible with adult life and pregnancy. A better understanding of the enzymatic deficiencies and new technologies have made recombinant enzyme replacement therapy possible. Along with early diet manipulation, current management allows many patients to live relatively normal lives. Because fertility may not be affected, some of these conditions will be encountered by the anesthesiologist. This chapter describes diseases caused by certain enzyme deficiencies and the by-products that cause symptoms. Some are exacerbated by pregnancy and the stress of labor and delivery. The anesthesiologist plays an essential role in reducing physiologic stress and avoiding triggering agents and routines that cause severe metabolic derangements or cardiopulmonary decompensation. The final portion of the chapter describes the most recent advances in the prevention and treatment of malignant hyperthermia in pregnancy, discussing the impact on mother and baby.

A number of endocrinopathies may complicate pregnancy with significant adverse effects on the mother and fetus. Diagnosis may prove difficult because of a long differential, and pregnancy can mask or mimic signs and symptoms of endocrine disease. Thyroid disease and diabetes are relatively common during pregnancy; however, serious complications such as thyroid storm and diabetic ketoacidosis are rare. Uncommon complications of hyperthyroidism and diabetes are discussed in this chapter along with other rare endocrinopathies

In utero intervention for fetal anomalies or abnormal placentation should only occur for conditions known to result in ongoing irreversible harm to the fetus or increased risk to the mother. For in utero fetal treatment procedures there should be evidence that potential harm from the fetal lesion is best mitigated by intervention at a gestational age with superior outcomes than ex utero neonatal treatment. Although most fetal anomalies are not amenable to in utero treatment, two conditions with significant evidence of improved outcomes include use of fetoscopic laser photocoagulation to treat twin-to-twin transfusion syndrome and mid-gestational in utero open fetal surgery to treat myelomeningocele. Minimally invasive fetal treatment techniques are typically performed under local or regional anesthesia, while open fetal procedures are done under general anesthesia. Successful fetal intervention requires extensive multidisciplinary planning and collaboration. In addition to anesthetic considerations employed for nonobstetric surgery during pregnancy, fetal anesthesia and analgesia, fetal monitoring, uterine relaxation, and preparation for emergent maternal and fetal events are all necessary. Future research into anesthetic techniques for various maternal-fetal procedures is key to optimizing clinical outcomes and advancing the field of fetal surgery and maternal-fetal medicine.